OR Manager - January 2018 - 21

Finances
90 days after hospital discharge
* Model 3. post-acute care services
with a skilled nursing facility, inpatient
rehabilitation facility, long-term
care hospital or home health agency
* Model 4. CMS makes a single, prospectively
determined bundled payment
to the hospital that encompasses
all services furnished by the
hospital, physicians, and other practitioners
during the episode of care,
which lasts the entire inpatient stay.
Adoption of BPCI in the form of a
CABG bundle has been successful both
clinically and fiscally at UMass Memorial
Health Care, Wood told OR Manager.
" Initially
there was resistance from
primary care physicians and cardiologists
who did not understand what we
were trying to do, " Wood says. " As
the navigator, I started looking at our
processes and clinical
indicators like
length of stay, readmission rates, use
of visiting nurse associations [VNAs]
at discharge and readmission rates,
and discharge to skilled nursing facilities
[SNFs] and associated readmission
rates, " she says.
Since implementation of the bundle,
however, she says the discharge to SNF
rate has dropped from 25% to less than
10% (sometimes down to 7%), and readmissions
have decreased from more
than 20% to less than 10%.
" Our SNF-related readmission rate
also dropped more than 20% and is
now closer to 7% to 8%, " she says.
Wood attributes these numbers to better
communication and a great deal of
staff education.
" The CABG bundle has altered our
plan of care significantly, " Wood says.
" For example:
* We use less visiting nursing services
and do more predischarge and inpatient
education. A 24-hour hotline is
staffed by a cardiac surgery provider
who in most cases was directly involved
in the patient's care. Patients
go home with a wrist band and a
folder, both of which prominently diswww.ormanager.com
play
the hotline phone number.
* We set up a clinic where patients
are seen Monday through Friday.
* We make a follow-up phone call on
postdischarge day 3 to encourage
the patients to call us directly for assessment
and questions.
* We have adopted the philosophy
that our patients are 'well,' not
'ill,' and we continue to reinforce
the idea so they are prepared to go
home. More than 85% of patients
are discharged to home instead of
a SNF. "
Margo Wood,
DNP, ACNPBC,
FNP-BC
In addition, Wood says,
she did a root-cause
analysis of readmissions.
" As a service, we
identified ways to prevent
the problem. For
example, we use more
aggressive beta blockers
and electrolyte management
for atrial fibrillation
and more aggressive diuresis for
pleural effusion. "
The Baptist Health System in San
Antonio, Texas, also has benefited from
participating in BPCI. An observational
study of 3,942 lower extremity joint replacement
patients at Baptist Health
System in 2017 showed reductions
in Medicare episode expenditures (a
20.8% drop for 3,738 episodes of joint
replacement without complications and
a 13.8% drop for 204 episodes of joint
replacement with complications).
The biggest savings came from the
average 29% reduction per case in implant
costs, which was attributed to the
collaboration between surgeons and
the hospital to negotiate lower prices.
But postdischarge stays also cost less
thanks to the focus on the entire episode
of care, which is the cornerstone
of VBC.
" Most providers have also reduced
costs for joint replacements by increasing
the percentage of patients discharged
to home, " Peters notes.
A cloudier picture of BPCI, however,
emerged in the 2017 report from the
Adoption of a
cardiac bundle has
lowered
readmission rates.
Lewin Group, which evaluates the efficacy
of BPCI each year. The report,
which analyzed data for 2013 to 2015,
found that Medicare payments for joint
replacements decreased an average of
$1,273 (4.5%) per case.
" The BPCI initiative tests a wide
range of configurations, including the
three bundled payment models and
multiple options for providers and other
organizations to participate in up to 48
clinical episodes, " the authors say.
" Because of the vast range of situations
encompassed under the initiative,
including the selective and heterogeneous
group of participants and limited,
varied experience of participants, it is
challenging to reach conclusions about
the impact of BPCI overall. "
CJR initiative
Under CMS's Comprehensive Care for
Joint Replacement (CJR) program, which
went into effect in late 2015, some 800
hospitals in 67 geographic areas were
required to meet CJR criteria for hip and
knee replacements. Under this model,
participants would be held accountable
for outcomes associated with the entire
episode of care, from admission to 90
days postdischarge.
At the end of November 2017, however,
CMS finalized the cancellation of
the mandatory hip fracture and cardiac
bundled payment models and implemented
changes to the CJR model.
CMS reduced the number of mandatory
geographic areas participating in CJR
from 67 to 34 areas and made participation
voluntary for all low-volume and
rural hospitals involved in the model.
In addition, CMS cancelled the Episode
Payment Models and the Cardiac
Continued on page 27
OR Manager | January 2018 21
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OR Manager - January 2018

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